Prevention of Future Deaths reports · 2024

William Lardner

Regulation 28 report to prevent future deaths, reference 2024-0670, written 5 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report5 Dec 2024
Reference2024-0670
DeceasedWilliam Lardner
CoronerRachael Griffin
Coroner areaDorset
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (2)

NOTE: This form is to be used before an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Managing Director of Bournemouth International Airport Ltd

2. Chief Executive of BCP Council

1 | CORONER

lam Rachael Clare Griffin, Senior Coroner, for the Coroner Area of Dorset.

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

3 | INVESTIGATION

On the 5" July 2023 | commenced an investigation into the death of William Albert
Nairn Lardner, aged 16 years. The investigation has not yet concluded, and the
Inquest has not yet been heard.

4 | CIRCUMSTANCES OF THE DEATH

On the evening of the 30° June 2023, William, known as Billy, had been working
at one of the concessions at Bournemouth Airport. He finished work at
approximately 9.30pm and walked from the airport main building, down Hurn
Court Lane, the road upon which the airport is situated, towards the traffic lights
on Parley Lane, Christchurch the main road outside the airport. Billy’s brother had
arranged to collect Billy from work that evening. At approximately 9.34pm Billy
was crossing Parley Lane at the traffic lights, at the junction with Hurn Court Lane,
towards his brother’s car which had stopped at the lights when he was struck by
a vehicle which had gone through a red light at speed. He sustained significant,
traumatic injuries which led to his death.

5 | CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to
concern. In my opinion there is a risk that future deaths could occur unless action
is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. —

(1) Bournemouth International Airport is a busy passenger airport with daily
flights operating from the airport. A recent article on the airport's website
on the 25t" November 2024 marked their one millionth passenger for 2024.
This article reports a rise in passenger numbers and plans for anticipated
future growth with a series of new routes.

(2) Passengers using Bournemouth Airport can access the airport by car,
whether that is a private vehicle or a taxi. There is airport parking available

for 2250 passengers and 213 staff. There is a drop off area. The minimum
charge to access the airport drop off zone is £5 for 30 minutes, which is
said to be standard airport industry practice.

(3) There is limited access to the airport by public transport. There is no

access by train and there is one bus service from central Bournemouth to
the airport. This bus service only operates Monday to Friday with a total of
5 journeys a day: 2 inbound journeys which are from Westover Road,
Bournemouth to the Airport, one between 05.50 and 06.31 hours and then
the other between 06.35 to 07.22 hours and 3 outbound journeys from
Bournemouth Airport to Westover Road, Bournemouth between 13.53 to
14.25 hours, 16.20 and 17.20 hours and 18.00 to 18.49 hours. This service
focuses on providing a service for staff working at the neighbouring
Aviation Business Park, however, does also serve the main passenger
terminal. Previously, the airport was served by an hourly bus service,
however this was stopped.

(4) Many people access the airport on foot, either being dropped off and/or

picked up on Parley Lane where there is no layby or drop off zone or by
using nearby car parks and walking on foot to the airport. One such car
park is at the Adventure Wonderland site and is known as Parley Lane
Parking (Parley Lane Parking | Bournemouth Airport Parking). This is 0.9
miles from the airport, on the opposite side of Parley Lane which offers
cheaper rates than Bournemouth Airport to park. There is no pathway on
the side of the road at Parley Lane Parking and no crossing facility, so
people will either walk along the road or have to cross the road to access
the footpath. Please see attached photograph at JGL/5.

(5) Parley Lane is a busy single carriageway semi-rural road with a national

speed limit and BCP Council has responsibility for the road as the local
highway authority. Hurn Court Lane is owned by the airport who therefore
have responsibility for it. There is no public footpath along Hurn Court Lane
after turning off Parley Lane to access the airport. Please see attached
photograph at JGL/4. This results in pedestrians walking in the road or on
the grass section next to the road on Hurn Court Lane to get to the airport
terminal. This is dangerous as it is not a stable, safe public pathway and
could lead to people falling into the road or being struck by vehicles,
especially as people pull suitcases along. The airport has erected signs
stating these is no pedestrian access, however, these are widely ignored.

(6) Asite visit and assessment in July 2023 by Dorset Police Road Casualty

Reduction Officer and the Senior BCP Council Safety Officer following
Billy’s death highlighted some fundamental safety issues. At this time no
action has been taken around these safety issues, although matters have
been discussed. Accordingly, the safety issues remain the same 17
months on from the site assessment, with a likely increasing number of
passengers using the airport going forward.

(7) |, therefore, have concerns that there could be future deaths given the

manner in which users are accessing the airport and the lack of public
transport and pedestrian access available.

ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and | believe
you and your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 30" January 2025. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise, you must explain why no action is
proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons, namely Billy’s family and ||, and to the Local Child
Safeguarding Board. | have also sent it to Dorset Police Road Casualty Reduction
Officer, Regional and City Airports and the Highways Agency who may find it
useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he believes
may find it useful or of interest. You may make representations to me, the coroner,
at the time of your response, about the release or the publication of your response
by the Chief Coroner.

Dated Signed

5' December 2024 Rachael C Griffin

JGL/5 - Photograph showing entrance to alternative airport parking at Adventure Wonderland.

BS

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Bcp Council (PDF)
Chief Executive  
BCP Civic Centre 
Bourne Avenue 
Bournemouth  
BH2 6DY  

HM Coroner Mrs Rachael Griffin 
Coroner’s Office 
Civic Centre 
Bournemouth   
BH2 6DY 

Date:         29 January 2025 
Our Ref:    
Contact:    
Email:        

Dear Coroner, 

William Albert Nairn Lardner deceased 

I write in response to your Regulation 28 Report to prevent future deaths, received on the 5 
December 2024 following your investigation into the tragic death of William Albert Nairn 
Lardner. 

You have asked for a response to several matters of concern in your report and I set out my 
responses, including what action is to be taken and a timetable for that action, below. I have 
not responded to the first two matters of concern as I do not believe the Council is required 
to respond to these points. 

3)  Matter of concern: There is limited access to the airport by public transport. There is 
no access by train and there is one bus service from central Bournemouth to the 
airport. This bus service only operates Monday to Friday with a total of 5 journeys a 
day: 2 inbound journeys which are from Westover Road, Bournemouth to the Airport, 
one between 05.50 and 06.31 hours and then the other between 06.35 to 07.22 
hours and 3 outbound journeys from Bournemouth Airport to Westover Road, 
Bournemouth between 13.53 to 14.25 hours, 16.20 and 17.20 hours and 18.00 to 
18.49 hours. This service focuses on providing a service for staff working at the 
neighbouring Aviation Business Park, however, does also serve the main passenger 
terminal. Previously, the airport was served by an hourly bus service, however this 
was stopped. 

BCP Council response, action and timescale: The current bus service is operated by 
Morebus and provides a service including 5 journeys per day Monday to Friday as outlined 
in your report. The previous hourly bus service was funded by the Airport.  

The Council shall work with the airport to investigate if/how the previous service could be 
reinstated, or the frequency of bus services to the airport increased.  This may need to be 
facilitated by the securing of funding from new development(s) at/in the vicinity of the airport. 

4)  Matter of concern: Many people access the airport on foot, either being dropped off 
and/or picked up on Parley Lane where there is no layby or drop zone or by using 
nearby car parks and walking on foot to the airport. One such car park is at the 
Adventure Wonderland site and is known as Parley Lane Parking (Parley Lane 
Parking | Bournemouth Airport Parking). This is 0.9 miles from the airport, on the 
opposite side of Parley Lane which offers cheaper rates than Bournemouth Airport to 
park. There is no pathway on the side of the road at Parley Lane Parking and no 
crossing facility, so people will either walk along the road or have to cross the road to 
access the footpath. Please see attached photograph at JGL/5. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 BCP Council response, action and timescale: A retrospective application for a change of 
use to a commercial car park at Adventure Wonderland was refused on the 10 January 
2025.  
The council has undertaken pedestrian counts at the location to assess if there is sufficient 
demand to warrant investment in a pedestrian crossing facility.  The assessment involved 
two hour long pedestrian count surveys. One survey took place when an outbound flight was 
scheduled outside of the operational hours of the shuttle service, and this found that no 
pedestrians crossed at this location. The second survey was undertaken during the 
operating hours of the shuttle service, two pedestrians crossed Parley Lane to the Parley 
Lane parking site.  
If/when the application for use of the site as a commercial car park, or a new application is 
submitted then the council shall re-assess the need to secure the installation of a pedestrian 
crossing and pathway at this location.   

5)  Matter of concern: Parley Lane is a busy single carriageway semi-rural road with a 
national speed limit and BCP Council has responsibility for the road as the local 
highway authority. Hurn Court Lane is owned by the airport who therefore have 
responsibility for it. There is no public footpath along Hurn Court Lane after turning off 
Parley Lane to access the airport. Please see attached photograph JGL/4. This 
results in pedestrians walking in the road or on the grass section next to the road on 
Hurn Court Lane to get to the airport terminal. This is dangerous as it is not a stable, 
safe public pathway and could lead to people falling into the road or being struck by 
vehicles, especially as people pull suitcases along. The airport has erected signs 
stating there is no pedestrian access, however, these are widely ignored. 

BCP Council response, action and timescale: Note: the site description in point 3 refers 
to Hurn Court Lane north of the junction, however, the photo shows Hurn Court Lane south 
of the junction.  This response is regarding Hurn Court north.  The council responsibility for 
the highway ends approximately 15 metres north (from the signalised junction) along Hurn 
Court Lane towards the Airport where the speed limit signs are located. Up to this point there 
is a pavement (footway).  

Although the council is not responsible for the provision of a pavement (footway) beyond the 
speed limit signs it does recognise that the provision of a pavement (footway) up to and into 

 
 
 
 
 
 
 
 the airport would be beneficial and shall support the airport to progress the construction of 
one.   

6)  Matter of concern: A site visit and assessment in July 2023 by Dorset Police Road 

Casualty Reduction officer and the Senior BCP Council Safety Officer following Billy’s 
death highlighted some fundamental safety issues. At this time no action has been 
taken around these safety issues, although matters have been discussed. 
Accordingly, the safety issues remain the same 17 months on from the site 
assessment, with a likely increasing number of passengers using the airport going 
forward. 

BCP Council response, action and timescale: Following the site visit between Dorset 
Police and BCP Council, four actions points were agreed. Two of these were street lighting 
related and completed by Dorset Council which forwarded requested information to Dorset 
Police.  

The other two actions were to review the speed limit on Parley Lane including assessing the 
location for a vehicle activated sign and to check the operation of the pedestrian facilities on 
the crossing facilities at the junction of Hurn Court Lane and Parley Lane.  

The speed limit review has been completed and the reduction of the speed limit from 60 to 
40mph is currently being consulted upon. The intent is to have implemented the 40mph 
speed limit by July 2025.   An assessment for a vehicle activated sign shall follow when the 
speed limit has been reduced to 40mph.  

The operation of the pedestrian facilities at the junction was checked by BCP signals 
contractor and confirmed as working on 9/1/24.  The operation of the pedestrian crossing 
facilities has been re-checked in January 2025 and confirmed as working correctly.   

Further to these points, the Police raised some areas of concern as follows: 

a)  The pedestrian crossing facility on Parley Lane near to the junction of the airport 
allows pedestrians to cross the road towards the opposite junction, but the 
footpath in the opposite junction comes to an end in all directions and serves no 
purpose. Can I ask what the intended purpose of this footpath is? I believe it 
encourages members of the public to be dropped off in the opposite junction. I 
have highlighted where the footpath leads to and comes to an end (Fig. 1 and 2).  

Fig. 1   

Fig.2 

BCP Council response: This junction was reconfigured between 2009 and 2011 by Dorset 
County Council (who were responsible for the highway at that time). Dorset County Council 
designed and constructed the signalised junction with pedestrian and cycling crossing 
facilities to future proof it to accommodate future walking and cycle movements in the area, 
for example pedestrians and cyclists from the north Bournemouth area crossing the Stour 
and using Hurn Court Lane (South) to get to and across Parley Lane as a part of their 
journey. 

b)  Once members of the public have negotiated crossing the road from the opposite 
junction there is no footpath into the airport and pedestrians are using the road or 
grass to walk into the airport, pedestrians with suitcases tend to use the road 
rather than the grass. There is signage present but is being ignored (Fig.3). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig.3 

BCP Council response: As per reply to item 5 above.  The land to the north of the 
signalised junction beyond the 20mph speed limit signs is the responsibility of private 
landowners who are responsible for the provision of any walking and cycling facilities on 
their land. The following plan (Fig.4.) and street view (Fig.5) show the council highway 
extent. 

Priva
te 

BCP Council 
Highway 

Priva
te 

BCP Council 
Highway 

Fig.4 

Fig.5 

 
 
 
 
 
 
 
 
 c)  Adventure Wonderland is now offering a slightly cheaper alternative airport 

parking/transfer option (Parley Lane Parking | Bournemouth Airport Parking), this 
raises another pedestrian safety issue as there is no crossing facility to safely get 
from Adventure wonderland to the opposite footpath with no other option but to 
cross the road. The risk is also heightened as this is a national speed limit road 
(Fig.6 and Fig.7). 

Fig.6 

Fig.7 

BCP Council response: Please see responses to items 4 and 6 above. 

I trust that these responses assure you that the council has considered and acted upon your 
Regulation 28 Report.  I shall continue to ensure that actions that are currently in progress 
are completed as soon as possible.  

Yours sincerely, 

Chief Executive
Response from Bournemouth Airport (PDF)
30 January 2025

Rachael C Griffin,
Senior Coroner for the County of Dorset

cc: 

 Coroner’s Support Officer

By email only:

Dear Senior Coroner Griffin

Re. William Albert Nairn Lardner ("Billy" - as per the family's wishes), ref. 32399640

Thank you for the prevention of future deaths report dated 5 December 2024.

This response is made on behalf of Bournemouth Airport ("BOH") under paragraph 7(2) of Schedule 5 of
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013. In doing so, BOH understands that it is required to provide details of any action that has been taken,
or which it is proposed will be taken in response to the report, or otherwise, and set out a timetable of the
action taken or proposed to be taken; or provide an explanation as to why no action is proposed.

In providing this response, BOH would again like to convey sincere condolences to the family for the loss
of Billy in such tragic circumstances.

Background

BOH wishes to stress that Billy's death and the accident did not occur as result of any actions or omissions
on its behalf.

First, the driver of the car was found to have been impaired by alcohol and was driving at between 85
mph and 119 mph at the time of the accident. The driver was sentenced to 11 years imprisonment after
pleading guilty to the offences of Causing Death by Dangerous Driving, Failing to Stop and Driving without
Insurance.

Second, the accident did not occur on land owned or controlled by BOH. The accident occurred on Parley
Lane which is the main public highway outside of BOH. BOH does not own and has no responsibility for
Parley  Lane.  Bournemouth,  Christchurch  and  Poole  Council  ("BCP")  and  the  Highways  Agency  are
responsible for Parley Lane.

 Concerns

Although the accident did not occur on land controlled by BOH, the report sets out concerns around the
access  arrangements  to  BOH's  terminal,  namely:  (i)  there  is  limited  access  to  the  airport  by  public
transport: there is no train and only one bus service; (ii) some  passengers walk to the airport on foot,
either  being  dropped  off  and  or  picked  up,  from  nearby  areas  like  Parley  Lane  and  Adventure
Wonderland's  Parley  Lane  Parking  (as  referenced  by  the  Senior  Coroner);  and  (iii)  there  is  no  public
footpath along Hurn Court Lane after turning off Parley Lane to access the airport.

It  is  also  noted  that  the  report  states  that  no  action  has  been  taken  in  response  to  the  site  visit  and
assessment in July 2023 by Dorset Police and BCP Council.

Action

BOH and BCP met on 19 December 2024 and 23 January 2025 to discuss the concerns raised in the
report.

Taking each in turn:

1. Public  Transport: As  part  of  airport  expansion  plans,  there  has  been  positive  engagement  to
improve public transport to the airport between BOH, BCP and the local bus operator.  An indicative
enhanced  timetable  has  been  developed  to  meet  the  needs  of  current  and  future  staff  at
changeover  times  as  well  as  continuing  to  provide  opportunities  for  passengers  to  access  the
airport by bus. It is intended that the service will operate at an increased frequency and will continue
to provide a key link to Bournemouth town centre and railway station, to allow interchange with
other  public  transport  services.  Final  negotiations  are  currently  underway  to  agree  suitable
contributions from the airport to support these additional journeys and to encourage an increased
uptake in bus travel to the airport. Until these negotiations are concluded, BOH cannot set out a
precise timetable.

2. Parley  Lane/  Adventure  Wonderland:  BOH  has  no  control  over  Parley  Lane,  Parley  Lane
Junction,  or  the  Adventure  Wonderland  Parley Lane  Car  Park. BOH  cannot  take any action  in
respect of these areas and can, therefore, only make representations to BCP about what should
happen, which  it has done. Following  the meetings with BCP,  it is understood that (i) BCP are
intending to reduce the 60mph speed limit to 40mph on Parley Lane which is currently subject to
consultation;  (ii)  BCP  have  refused  a  retrospective  planning  application  associated  with  the
Adventure Wonderland Parley Lane Car Park operation; and (iii) BCP have checked the controlled
crossing operation.

3. Hurn Court Lane Pedestrian Access: BOH has developed plans and will construct a pedestrian
footpath alongside  the  part  of  Hurn  Court  Lane owned  by  BOH,  with  the  support  of  BCP.  The
delivery will be subject to permitted development consultation, but the build plans will be developed
in parallel so as the works can be completed in a timely manner. It is hoped that any footpath can
be completed within the next 3-6 months.

 With regards to the site visit and assessment in July 2023 by Dorset Police and BCP, any remedial action
was  directed  towards  Dorset  Council,  BCP  and  or  the  Police.  BOH,  therefore,  does  not  propose  to
comment specifically on the remedial actions identified in the relevant site assessment.

BOH trusts that this letter adequately responds to the prevention of future deaths report. If you require
further information, please let me know.

Yours sincerely,

Managing Director
Bournemouth International Airport Limited

:

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